Microsurgical Resection of Glomus Jugulare Tumors With Facial Nerve Reconstruction: 3-Dimensional...
MD, Duarte N C Cândido,;de Oliveira, MD, PhD, Jean Gonçalves;PhD, Luis A B Borba, MD,
2018-05-08 00:00:00
SURGICAL VIDEO Microsurgical Resection of Glomus Jugulare Tumors With Facial Nerve Reconstruction: 3-Dimensional Operative Video ∗ § Duarte N.C. Cândido, MD , Jean Gonçalves de Oliveira, MD, PhD , ∗ ‡ Luis A. B. Borba, MD, PhD Hospital Universitário Evangélico de Curitiba, Department of Neurosurgery, Curitiba, Paraná Brazil; Federal University of Parana, Department of Neurosurgery, Curitiba, Paraná, Brazil; Division of Neurosurgery, Department of Surgery, Santa Casa de São Paulo School of Medical Sciences (FCMSCSP) and Division of Cerebrovascular and Skull Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy100 Base surgery, Center of Neurology and Neurosurgery Associates (CENNA), Hospital Beneficência Portuguesa de São Paulo-SP, Brazil Correspondence: Luis A. B. Borba, MD, PhD, Rua Gen. Carneiro, 181 - Alto da Glória, Curitiba, Paraná, Brazil, 80060–900. E-mail: luisborba@me.com and computed tomography scans demonstrated a typical Paragangliomas are tumors originating from the paragan- lesion with intense flow voids at the jugular foramen glionic system (autonomic nervous system), mostly found region with invasion of the petrous and tympanic bone, at the region around the jugular bulb, for which reason carotid canal, and middle ear, and extending to the they are also termed glomus jugulare tumors (GJT). infratemporal fossa (type C2 of Fisch’s classification for Although these lesions appear to be histologically benign, GJT). During the procedure the mastoid part of the facial clinically they present with great morbidity, especially nerve was identified involved by tumor and needed to due to invasion of nearby structures such as the lower be resected. We also describe the technique for nerve cranial nerves. These are challenging tumors, as they reconstruction, using an interposition graft from the great need complex approaches and great knowledge of the skull base. We present the case of a 31-year-old woman, auricular nerve, harvested at the beginning of the surgery. operated by the senior author, with a 1-year history We achieved total tumor resection with a remarkable of tinnitus, vertigo, and progressive hearing loss, that postoperative course. The patient also presented with evolved with facial nerve palsy (House-Brackmann IV) facial function after 6 months. The patient consented with 2 months before surgery. Magnetic resonance imaging publication of her images. KEY WORDS: Paraganglioma, Glomus jugulare, Skull base, Facial nerve Operative Neurosurgery 0:1, 2018 DOI:10.1093/ons/opy100 Received, December 7, 2017. Accepted, April 8, 2018. optimal management of these lesions. A growing body of literature shows Disclosure that these lesions, even those of moderate size as presented in this case, The authors have no personal, financial, or institutional interest in any of the respond favorably to stereotactic radiosurgery (SRS). One could argue drugs, materials, or devices described in this article. that the facial nerve grafting performed as part of this procedure has some advantages in the long run as it provides some degree of facial nerve COMMENT recovery, albeit incomplete. Whether the technique utilized provides measurable facial nerve improvement from a functional and cosmetic he authors present a video demonstrating surgical management of perspective over less aggressive strategies could be debated. An alternative a glomus jugular tumor (GJT). The case is nicely presented with strategy perhaps at least worthy of mention would be SRS followed by less appropriate imaging, clinical history, surgical videos, relevant cadaveric invasive facial reanimation procedures. All this issues aside, the authors anatomical dissections, and video of the patient including facial nerve are to be congratulated on excellent technique, and a “how to do it” video function before, immediately after, and at 6-month follow-up. The of an established surgical technique that is well done. patient’s outcome for this challenging GJT is very good. This is not a new technique, but does provided a nice demonstration of how Michael Chicoine to manage these lesions surgically, particularly for surgeons without St. Louis, Missouri experience with this technique. That said, it is somewhat debatable as to OPERATIVE NEUROSURGERY VOLUME 0 | NUMBER 0 | 2018 | 1 Downloaded from https://academic.oup.com/ons/advance-article-abstract/doi/10.1093/ons/opy100/4993890 by Ed 'DeepDyve' Gillespie user on 12 July 2018
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Abstract

SURGICAL VIDEO Microsurgical Resection of Glomus Jugulare Tumors With Facial Nerve Reconstruction: 3-Dimensional Operative Video ∗ § Duarte N.C. Cândido, MD , Jean Gonçalves de Oliveira, MD, PhD , ∗ ‡ Luis A. B. Borba, MD, PhD Hospital Universitário Evangélico de Curitiba, Department of Neurosurgery, Curitiba, Paraná Brazil; Federal University of Parana, Department of Neurosurgery, Curitiba, Paraná, Brazil; Division of Neurosurgery, Department of Surgery, Santa Casa de São Paulo School of Medical Sciences (FCMSCSP) and Division of Cerebrovascular and Skull Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy100 Base surgery, Center of Neurology and Neurosurgery Associates (CENNA), Hospital Beneficência Portuguesa de São Paulo-SP, Brazil Correspondence: Luis A. B. Borba, MD, PhD, Rua Gen. Carneiro, 181 - Alto da Glória, Curitiba, Paraná, Brazil, 80060–900. E-mail: luisborba@me.com and computed tomography scans demonstrated a typical Paragangliomas are tumors originating from the paragan- lesion with intense flow voids at the jugular foramen glionic system (autonomic nervous system), mostly found region with invasion of the petrous and tympanic bone, at the region around the jugular bulb, for which reason carotid canal, and middle ear, and extending to the they are also termed glomus jugulare tumors (GJT). infratemporal fossa (type C2 of Fisch’s classification for Although these lesions appear to be histologically benign, GJT). During the procedure the mastoid part of the facial clinically they present with great morbidity, especially nerve was identified involved by tumor and needed to due to invasion of nearby structures such as the lower be resected. We also describe the technique for nerve cranial nerves. These are challenging tumors, as they reconstruction, using an interposition graft from the great need complex approaches and great knowledge of the skull base. We present the case of a 31-year-old woman, auricular nerve, harvested at the beginning of the surgery. operated by the senior author, with a 1-year history We achieved total tumor resection with a remarkable of tinnitus, vertigo, and progressive hearing loss, that postoperative course. The patient also presented with evolved with facial nerve palsy (House-Brackmann IV) facial function after 6 months. The patient consented with 2 months before surgery. Magnetic resonance imaging publication of her images. KEY WORDS: Paraganglioma, Glomus jugulare, Skull base, Facial nerve Operative Neurosurgery 0:1, 2018 DOI:10.1093/ons/opy100 Received, December 7, 2017. Accepted, April 8, 2018. optimal management of these lesions. A growing body of literature shows Disclosure that these lesions, even those of moderate size as presented in this case, The authors have no personal, financial, or institutional interest in any of the respond favorably to stereotactic radiosurgery (SRS). One could argue drugs, materials, or devices described in this article. that the facial nerve grafting performed as part of this procedure has some advantages in the long run as it provides some degree of facial nerve COMMENT recovery, albeit incomplete. Whether the technique utilized provides measurable facial nerve improvement from a functional and cosmetic he authors present a video demonstrating surgical management of perspective over less aggressive strategies could be debated. An alternative a glomus jugular tumor (GJT). The case is nicely presented with strategy perhaps at least worthy of mention would be SRS followed by less appropriate imaging, clinical history, surgical videos, relevant cadaveric invasive facial reanimation procedures. All this issues aside, the authors anatomical dissections, and video of the patient including facial nerve are to be congratulated on excellent technique, and a “how to do it” video function before, immediately after, and at 6-month follow-up. The of an established surgical technique that is well done. patient’s outcome for this challenging GJT is very good. This is not a new technique, but does provided a nice demonstration of how Michael Chicoine to manage these lesions surgically, particularly for surgeons without St. Louis, Missouri experience with this technique. That said, it is somewhat debatable as to OPERATIVE NEUROSURGERY VOLUME 0 | NUMBER 0 | 2018 | 1 Downloaded from https://academic.oup.com/ons/advance-article-abstract/doi/10.1093/ons/opy100/4993890 by Ed 'DeepDyve' Gillespie user on 12 July 2018